www.it-ebooks.info www.it-ebooks.info Meaningful Use and Beyond Fred Trotter and David Uhlman Beijing • Cambridge • Farnham • Köln • Sebastopol • Tokyo www.it-ebooks.info Meaningful Use and Beyond by Fred Trotter and David Uhlman Copyright © 2011 Fred Trotter and David Uhlman. All rights reserved. Printed in the United States of America. Published by O’Reilly Media, Inc., 1005 Gravenstein Highway North, Sebastopol, CA 95472. O’Reilly books may be purchased for educational, business, or sales promotional use. Online editions are also available for most titles (http://my.safaribooksonline.com). For more information, contact our corporate/institutional sales department: (800) 998-9938 or corporate@oreilly.com. Editor: Andy Oram Production Editor: Jasmine Perez Copyeditor: Teresa Horton Proofreader: O’Reilly Production Services Cover Designer: Karen Montgomery Interior Designer: David Futato Illustrator: Robert Romano Revision History for the First Edition: See http://oreilly.com/catalog/errata.csp?isbn=9781449305024 for release details. Nutshell Handbook, the Nutshell Handbook logo, and the O’Reilly logo are registered trademarks of O’Reilly Media, Inc. Meaningful Use and Beyond and related trade dress are trademarks of O’Reilly Media, Inc. Many of the designations used by manufacturers and sellers to distinguish their products are claimed as trademarks. Where those designations appear in this book, and O’Reilly Media, Inc., was aware of a trademark claim, the designations have been printed in caps or initial caps. While every precaution has been taken in the preparation of this book, the publisher and authors assume no responsibility for errors or omissions, or for damages resulting from the use of the information con- tained herein. ISBN: 978-1-449-30502-4 [LSI] 1317908625 www.it-ebooks.info Table of Contents Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii 1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Health IT and Medical Science 3 Meaningful Use and What It Means to Be an EHR 4 Why So Late? 5 Health IT in Health Reform 7 Evolution of Meaningful Use 7 Accountable Care Organizations 8 EHR Functionality in Context 10 2. An Anatomy of Medical Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 How Patients Reach Healthcare Organizations 14 Lab Sample Collection Before a Visit or Admission Date 17 HIPAA and Patient Identification 17 Intake, Demographics, Visits, and Admissions 20 Precertification and Prior Authorization 21 Emergency Admissions 21 Prioritization and Triage 23 Outpatient Care 24 Inpatient Care 25 Labs 27 Imaging 27 Administration and Billing 28 3. Medical Billing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Who Pays, and How 32 Claims 32 Eligibility 33 Treatment 35 Billing 37 iii www.it-ebooks.info The Billing Process 38 Complexities in Billing 39 Adjudication 40 The Patient’s Burden 42 4. The Bandwidth of Paper . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Workflow Tokens 47 Why Leave Paper? 48 Step 0: Health IT Humility 49 Normalized Data 52 Good Boundaries Mean Good Data 53 Data at Peace with Itself: Linked Data 55 Flexible Data 56 Assume Health Data Changes 57 Free Text Data 57 5. Herding Cats: Healthcare Management and Business Office Operations . . . . . . . . . 61 Major Business Office Activities 63 Insurance 63 Records 64 Demographics 64 Revenue Collection 65 Auditing 65 Accounting 66 Reporting 66 Licensing, Credentials, and Enrollments 67 Nonhealthcare Interactions 68 The Evolution of the Business Office 68 6. Patient-Facing Software . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 The PHR as Platform 71 Sharing Data in Patient-Facing Software 75 Patients Using Normal Social Media 75 E-patients 77 The Quantified Self 78 Patient-Focused Social Media 80 Patient Privacy in PHR Systems 81 Specific PHR and Patient-Directed Meaningful Use Requirements 83 7. Human Error . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 The Extent of Error 85 Dangerous Dosing 87 Discontents of Computerization 90 iv | Table of Contents www.it-ebooks.info Process Errors and Organizational Change 92 Deep Medical Errors and EHR Solutions 94 Errors Caused by Human-Computer Mismatch 95 Best Practices 96 8. Meaningful Use Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 Outpatient Guidelines and Requirements 100 Inpatient Guidelines and Requirements 116 9. A Selective History of EHR Technology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129 MUMPS: The Programming Language for Healthcare 129 Where Can We Buy Some Light Bulbs? 130 Fragmentation 131 In an Environment with Gag Clauses and No Consumer Reports 131 VistA History 132 10. Ontologies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135 A Throw-Away Ontology 136 Learning from Our Example 138 CPT Codes, Sermo, and CMS 141 International Classification of Diseases (ICD) 144 E-patient-Dave-gate 145 Crosswalks and ICD Versions 147 Other Claims Codes 149 Drug Databases 149 SNOMED to the Rescue 154 SNOMED Example 155 SNOMED and the Semantic Web 157 UMLS: The Universal Mapping Metaontology 158 Extending Ontologies 159 Other Ontologies 160 Sneaky Ontologies 161 Ontologies Using APIs 162 Exercising Ontologies 162 11. Interoperability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165 Some Lessons from Earlier Exchanges 166 The New HIE Rules 168 Strong Standards 168 Winning Protocols 171 The Billing Protocols 171 HL7 Version 2 173 First-Generation and Second-Generation HIEs 182 Table of Contents | v www.it-ebooks.info Continuity of Care Record 182 HL7 v3, RIM, CDA, CDD, and HITSP C32 185 The IHE Protocol 189 HIE with IHE 191 Managing Patient Identifiers with IHE 192 IHE Data Exchange, the Library Model 193 IHE in the NWHIN 194 The Direct Project/Protocol 196 The PCAST Report 198 The SMART Platform 199 Technology and Policy Were Sitting in the Tree 199 12. HIPAA: The Far-Reaching Healthcare Regulation . . . . . . . . . . . . . . . . . . . . . . . . . . . 203 Does HIPAA Cover Me? 205 Responsibilities of Covered Entities 206 HIPAA: A Reasonable Regulation 213 Duct-Tape HIPAA Strategies 214 Breach Notification Rules 215 In Summary 217 13. Open Source Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219 Why Open Source? 220 Major Open Source Healthcare Projects 221 ClearHealth 222 Mirth Connect 223 VistA Variants and Other Certified Open Source EHR Systems 223 OpenMRS 224 Appendix: Meaningful Use Implementation Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . 227 vi | Table of Contents www.it-ebooks.info Preface Thousands of computer experts seek to enter the field of healthcare information tech- nology (health IT or HIT), and they are needed. In December 2009, the U.S. Depart- ment of Health and Human Services estimated that computerization just within the healthcare industry will add a need for 50,000 new IT staff. * These recruits to healthcare will bring valuable lessons learned through work in online commerce sites, financial institutions, or large corporate and university campuses, but they will be fundamentally bewildered during their first year or so at a hospital or clinic. Meaningful use is the focus of this book because it is the term used in the Health Care Reform and Health IT Stimulus Act (HITECH, part of the American Recovery and Reinvestment Act of 2009) to encompass a vision of improved healthcare through computerization and digital networks. There’s a great deal of nervousness among U.S. healthcare providers about meaningful use. Can they push their organizations into the twenty-first century vision it represents? Will their IT systems really support it, and even if certified for meaningful use this year, will the systems support it in the future? And even if hospitals and clinics adhere to the letter of the law, will they really reap the benefits promised by health IT? So meaningful use, for us, stands for much more than a set of requirements in a par- ticular set of U.S. regulations. It represents a form of care that empowers the patient, that does not harm her, that promotes long-term health, and that is affordable for everyone. To realize this vision, IT staff in hospitals and clinics have to understand how their particular institutions work and what roles they play. This book, so far as we know, is the first candid attempt to bridge the gap between clinicians and IT staff. It explains the factors that make healthcare settings different from other jobs and academic settings that computer staff may have come from—and that make the healthcare settings different from each other—so that readers enter these settings with a deep respect for their practices. We will not be reticent about sources of resistance to new computing opportunities. But we will give you a starting language for discussing the path to and beyond meaningful use. * Help Wanted: Skilled Health IT Workforce to Modernize Health Care A Message from Dr. David Blumenthal, National Coordinator for Health Information Technology, December 24, 2009. vii www.it-ebooks.info We don’t delve too deeply into technical details here, because they are fast changing. If we explained how to set up S/MIME for a direct email gateway, you might find that better options already exist when you get into the workplace. If we explained how to interact with the fields of a CCD, you would probably find that these fields are under- going constant change and that much of the data you deal with requires a different format. So this is a different type of technical book: a book that gives you a context for choosing and implementing the right technology for your organization. Audience We’ve directed our writing mostly at computer professionals, but this book can still be valuable for doctors, other clinicians, and other staff at healthcare institutions as well. We occasionally use terms from computer science and programming that will be fa- miliar to people from those fields and might not be known to other readers. But we think that even the general reader can skip over technical details that he or she doesn’t understand, and learn a lot about how to talk to other people about computers and networking in healthcare. Organization The chapters in this book are as follows. Chapter 1, Introduction An overview of the topics of this book, a discussion of differences between medical settings, and an overview of meaningful use, which will be fleshed out later in the book Chapter 2, An Anatomy of Medical Practice The wide variety of ways healthcare settings deal with patients and staff, and how workflows vary Chapter 3, Medical Billing A candid investigation into how providers charge for care and how they get paid Chapter 4, The Bandwidth of Paper An explanation of how deeply embedded paper records are in U.S. clinical settings, and what you need to do to migrate to electronic records Chapter 5, Herding Cats: Healthcare Management and Business Office Operations A review of what happens just outside the doors of the treatment room where administrative and IT staff perform traditional business operations Chapter 6, Patient-Facing Software A detailed look at how patients can use technology to become participants in their own care, including such notions as personal health records, online communities, and the quantified self viii | Preface www.it-ebooks.info [...]... comprehensive and fully featured systems exist to permit meaningful use compliance while using only open source software; these offerings provide an important reference and public resource for understanding meaningful use in technological terms or for real-world use Appendix, Meaningful Use Implementation Assessment A checklist to help you determine how close your institution is to becoming meaningful use compliant... today’s meaningful use requirements will not be able to meet tomorrow’s Thankfully, meaningful use includes the financial incentives mentioned in the previous section Its payments occur only when eligible entities prove that they are meaningful users of EHR systems, usually by reporting the details of how they use an EHR system certified for meaningful use As a result, the meaningful use standards will always... title, author, publisher, and ISBN For example: Meaningful Use and Beyond by Fred Trotter and David Uhlman (O’Reilly) Copyright 2011 Fred Trotter and David Uhlman, 978-1-449-30502-4.” If you feel your use of code examples falls outside fair use or the permission given above, feel free to contact us at permissions@oreilly.com Safari® Books Online Safari Books Online is an on-demand digital library that... deploying, and leveraging good health IT software, but it is useless to think about the purchase and use of EHR software in an environment that disincentivizes those activities These two concepts form what we call the VistA effect, which has turned the VA into the best hospital system in the world If you do not believe us, I again recommend Longman’s book Evolution of Meaningful Use Meaningful use is an... EHR software needs to do for the doctors, hospitals, and other eligible providers who purchase, use, and deploy the software to receive payments from the ARRA-HITECH stimulus plan In fact this has made the meaningful use requirements even more important than the term EHR What is an EHR? That which can be used by a clinician to achieve meaningful use Why So Late? IT experts, as well as the general public,... Evolution of Meaningful Use | 7 www.it-ebooks.info on specific measurable (and reportable) details of how an EHR system can operate You need to install a certified system, and use it in valuable ways The incentive schedule for HITECH is almost as important as the funds themselves The ARRA/HITECH incentives are only the beginning Institutions that adopt systems and use them in certified ways in 2011 and 2012... critical phase, when † The Use of Electronic Health Records in U.S Hospitals 6 | Chapter 1: Introduction www.it-ebooks.info meaningful use would first be defined You might call Dr Blumenthal an expert in nonmeaningful use Health IT in Health Reform But it is not enough to merely pay doctors to use EHRs The two counterexamples to systemic failure in health IT are Kaiser Permanente and the VA The key word... status, and many other measurable traits —than is several orders of magnitude deeper than it is today We must be able to gather and parse a hundred times more data about each patient than we do today, and we must be able to compare that rich data among millions of patients Today, the sciences and the software that support clinical trials, genomics, and standard clinical operations are separate and distinct,... over 7,500 technology and creative reference books and videos to find the answers you need quickly With a subscription, you can read any page and watch any video from our library online Read books on your cell phone and mobile devices Access new titles before they are available for print, and get exclusive access to manuscripts in development and post feedback for the authors Copy and paste code samples,... the use of computers to achieve standardization in data and work processes is a mantra It is almost beyond question that computerized automation of processes and record-keeping would dramatically improve the performance of any industry Still, healthcare has resisted computerization for decades In the answer to the question “Why hasn’t this happened on its own?” we will find the heart of meaningful use . www.it-ebooks.info www.it-ebooks.info Meaningful Use and Beyond Fred Trotter and David Uhlman Beijing • Cambridge • Farnham • Köln • Sebastopol • Tokyo www.it-ebooks.info Meaningful Use and Beyond by Fred Trotter and David. for release details. Nutshell Handbook, the Nutshell Handbook logo, and the O’Reilly logo are registered trademarks of O’Reilly Media, Inc. Meaningful Use and Beyond and related trade dress are. publisher, and ISBN. For example: Meaningful Use and Beyond by Fred Trotter and David Uhlman (O’Reilly). Copyright 2011 Fred Trotter and David Uhlman, 978-1-449-30502-4.” If you feel your use of